1. Surgical Repair of Iatrogenic Cervical Tracheal Stenosis
Nirmal K. Veeramachaneni, MD, Bryan F. Meyers, MD, MPH 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 13, Issue 1, Pages (March 2008)
DOI: /j.optechstcvs
Copyright © 2008 Elsevier Inc. Terms and Conditions

2. Figure 1
The patient is positioned supine, with the neck slightly extended. An inflatable bag is placed under the shoulders to permit exposure. Calf compression devices are used, in addition to subcutaneous heparin injection, to prevent deep vein thrombosis. After the induction of general anesthesia, bronchoscopy is performed to investigate the airway and to determine the location and length of the stricture. Rigid bronchoscopy may be required to temporarily dilate the stricture to permit endotracheal tube placement. A small armored endotracheal tube (Tovell) may be necessary. Because of the difficulties in securing an airway in the anesthetized patient with tracheal stenosis, the surgeon must be prepared to perform a tracheostomy.
The chest is prepped to facilitate sternal division should the need arise. A low collar incision is made.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 40-52DOI: ( /j.optechstcvs )
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3. Figure 2
After the incision is made, skin flaps are created. The flaps extend laterally to the sternocleidomastoid, superiorly to the level of the cricoid cartilage, and inferiorly to the level of the sternal notch. The sternohyoid and sternothyroid muscles are identified and retracted laterally to identify the midline.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 40-52DOI: ( /j.optechstcvs )
Copyright © 2008 Elsevier Inc. Terms and Conditions

4. Figure 3
The thyroid is dissected off the trachea and is often divided to expose the anterior surface of the trachea. The pretracheal plane is dissected as low as possible, as during the conduct of a cervical mediastinoscopy. Such a dissection facilitates tracheal mobility and exposure. Dissection should be conducted directly on the anterior surface of the tracheal wall to avoid injury to the recurrent laryngeal nerves, the esophagus, or vascular injury to the brachiocephalic artery. The use of electrocautery should be minimized.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 40-52DOI: ( /j.optechstcvs )
Copyright © 2008 Elsevier Inc. Terms and Conditions

5. Figure 4
The trachea in an average adult is 10 to 11 cm in length. It comprises 18 to 22 cartilaginous rings. Throughout its length, the trachea receives arterial blood supply in a segmental pattern from lateral vascular stalks. Therefore, during the mobilization of the trachea, circumferential dissection is to be avoided for extended lengths. In the young adult patient, as much as 50% of the length of the trachea may be resected, and an anastomosis may be performed without excessive tension. The length of resection is more limited in small children and in older adults with less pliable and calcified tracheal cartilage. a. = artery.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 40-52DOI: ( /j.optechstcvs )
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6. Figure 5
(A) The point of stenosis may not be readily evident on gross examination of the trachea. Puncture of the trachea with a small gauge needle while an assistant performs bronchoscopy with a pediatric bronchoscope will localize the point of stenosis. (B) Traction sutures are placed at the site of stenosis and the trachea is divided at the presumptive distal aspect of the stenosis.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 40-52DOI: ( /j.optechstcvs )
Copyright © 2008 Elsevier Inc. Terms and Conditions

7. Figure 6
An armored (Tovell) endotracheal tube is inserted into the distal airway and ventilation is continued using a sterile ventilation circuit into the operative field. Once the trachea has been transected, it is easier to determine the true proximal and distal extent of the stenosis. Once the distal ventilation has been established, the oral endotracheal tube may be withdrawn a few centimeters to permit proximal dissection, but it should not be removed entirely. To facilitate reintubation, a heavy suture is placed in the distal end of the endotracheal tube. This stitch allows for downward traction and proper positioning of the endotracheal tube at the end of the procedure.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 40-52DOI: ( /j.optechstcvs )
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8. Figure 7
Traction sutures are placed at the free edges of the cut trachea to facilitate retraction. The membranous trachea may then be safely dissected free of the esophagus, with minimal compromise of the lateral vascular pedicles, and with less risk to the recurrent laryngeal nerves. Complete mobilization along both the anterior and the posterior aspects of the trachea, well into the mediastinum, facilitates a tension-free anastomosis.
Once the proximal extent of the stenosis is defined, further resection is performed. The surgeon should be judicious and conservative in the extent of resection. It is always possible to resect more trachea, if the initial excision is unsatisfactory. The goal is to resect diseased trachea, leaving vascular, nonstenotic margins that are free of inflammation. The extent of resection must be balanced by the need to maintain tracheal length.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 40-52DOI: ( /j.optechstcvs )
Copyright © 2008 Elsevier Inc. Terms and Conditions

9. Figure 8
Once an adequate resection has been performed, the ease of tracheal reapproximation should be tested. (A) This is done by pulling the tracheal ends together using the lateral tracheal traction sutures, while the patient’s head is elevated by the anesthesiologist and the chin is flexed toward the chest wall. (B) Most resections allow a tension-free repair of the trachea if adequate anterior and posterior mobilization of the trachea has been performed. If the anastomosis is felt to be under excessive tension, a laryngeal release maneuver may be necessary. Both the thyrohyoid (Dedo) and the suprahyoid (Montgomery) maneuvers have been described to facilitate reconstruction of the upper and mid trachea. The suprahyoid release is associated with less risk of postoperative dysphagia and aspiration, and less risk of injury to the superior laryngeal nerve. An additional 1 to 2 cm of length may be gained with this maneuver. The authors have only rarely utilized this technique.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 40-52DOI: ( /j.optechstcvs )
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10. Figure 9
To perform the suprahyoid release, a small transverse incision is made directly over the hyoid bone. The superior aspect of the hyoid bone is exposed, and the tendons of the mylohyoid, geniohyoid, and genioglossus are divided. (A) The dissection is carried laterally to the digastric muscle attachments to the hyoid, which is preserved. The hyoid is then divided on both sides of the digastric attachment. This maneuver drops the larynx down, and dissection is completed by dividing the suprahyoid membrane and entering the preepiglottic space. (B) The incision is then closed over a closed section drain.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 40-52DOI: ( /j.optechstcvs )
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11. Figure 10
With the neck now in a degree of flexion, the membranous trachea is re-approximated. 3-0 Polyglactin stitches are used to approximate the junction of the membranous and cartilaginous portions of the two ends of the trachea. A 4-0 polydioxanone suture is then used to close the membranous trachea using a running stitch. Next, a series of 3-0 polyglactin sutures are used to close the cartilaginous portion of the trachea. All of the polyglactin sutures are placed and, before tying these stitches, the cross-table ventilation circuit is removed and the endotracheal tube is advanced. The previously placed traction stitch at the end of the endotracheal tube will assist the anesthesiologist in proper placement of the tube. The integrity of the anastomosis is assessed by deflating endotracheal tube cuff after irrigating the field with saline. The incision is then closed in multiple layers, after approximating the strap muscles.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 40-52DOI: ( /j.optechstcvs )
Copyright © 2008 Elsevier Inc. Terms and Conditions

12. Figure 11
A heavy suture is then placed to guard against excessive extension of the neck in the postoperative period. The suture is passed from the submental skin to the presternal skin. The purpose of this stitch is not to hold the neck in flexion but to serve as a “reminder” to avoid unintentional hyperextension. This suture is removed in 1 week and residual stiffness in the neck will limit hyperextension for some additional days after suture removal.
Patients are typically extubated at the end of the procedure. Careful observation for respiratory compromise is mandatory. The patient is kept NPO for 24 to 48 hours and cautiously started on a diet. The patient is monitored for evidence of aspiration. It has been our practice to perform fiberoptic bronchoscopy before discharge from the hospital.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 40-52DOI: ( /j.optechstcvs )
Copyright © 2008 Elsevier Inc. Terms and Conditions